Novel and Pandemic Influenza A Virus Infection Case Investigation Form
Case Information
Date of Report: _______/_______/_______(DD/MM/YYYY)
State/Local Case Identification Number: _____________________
CDC Case Identification Number: __________________________
Name of case-patient: Last ________________________ First_______________ Initials of case-patient (if not US case):_____________
Postal address: Street__________________________ Village/Town/City _________________________County/District_________________
State/Province____________ _______Zip Code/Postal Code_______________________
GIS coordinates of residence (Latitude Degrees/Minutes/Seconds X Longitude Degrees/Minutes/Seconds) _____________________________
Telephone #_____________________ Cell/Mobile _____________________ Fax _____________________ E-mail ___________________
Immigration status: US resident Resides abroad but visiting US
Reporter Information
Name of reporter: Last_____________________ First_____________________
Postal address: Street__________________________ City __________________ State/Province____________ Zip Code/Postal Code________
Telephone #_____________________ Cell/Mobile _____________________ Fax _____________________ E-mail ___________________
Reporter’s Organization:
State or County Health Department: _____________________ City_____________________ State/Province______________
Source of Information
Case-patient
Proxy; IF YES, relationship of proxy to case-patient_____________________ Reason for use of proxy_________________________________
Name of proxy: Last_____________________ First______________________
Postal address: Street__________________________ Village/Town/City _________________________County/District_________________
State/Province____________ _______Zip Code/Postal Code_______________________
Telephone #_____________________ Cell/Mobile _____________________ Fax _____________________
E-mail ___________________
Case-Patient Demographic Information
Date of Birth: _______/_______/_______(DD/MM/YYYY)
Race: White Asian American Indian/Alaska Native
Black Native Hawaiian/Other Pacific Islander Unknown
Ethnicity: Hispanic Non-Hispanic Unknown
Sex: Male Female
Social History and Contact Tracing
Number of household members (including case patient) _____________________
Does the case-patient have family members or close contacts with pneumonia or severe influenza-like-illness?
[close-contact defined as contact within 1 meter (or 3 feet) with a person (e.g. caring for, speaking with, or touching)]
Yes (complete contact form) No N/A Unknown
[If YES, list any identified contacts on the contact tracing form]
What is the current job of the case-patient? (check all that apply)
Laboratory worker Health care worker Poultry farm-worker Wildlife worker
Veterinary worker Other animal farm-worker
Other________________ Other animal husbandry _________________________
How long has the case-patient worked in their current job? (number) _______________ months years
If less than six months, list the type of job previously held: (specify job) ____________ (specify length of time at previous job) _________
Does the case-patient work in a health care facility or setting?
Yes (specify name)___________________________ No Unknown
Exposures- Travel history
In the 10 days prior to illness onset, did the case-patient travel?
Yes No Unknown
If YES, please fill in the arrival and departure dates for all countries visited.
Country____________ Arrival__________ Departure__________
Mode of Transportation______________ Flight/Ship #______________
Country____________ Arrival__________ Departure__________
Mode of Transportation______________ Flight/Ship #______________
Country____________ Arrival__________ Departure__________
Mode of Transportation______________ Flight/Ship #______________
Country____________ Arrival__________ Departure__________
Mode of Transportation______________ Flight/Ship #______________
Country____________ Arrival__________ Departure__________
Mode of Transportation______________ Flight/Ship #______________
Country____________ Arrival__________ Departure__________
Mode of Transportation______________ Flight/Ship #______________
Country____________ Arrival__________ Departure__________
Mode of Transportation______________ Flight/Ship #______________
Exposures-Contact with probable or confirmed case-patients
In the 10 days prior to illness onset:
Did the case-patient have close contact (within 1 meter (or 3 feet)) with a person (e.g. caring for, speaking with, or touching) with fever and cough, or pneumonia, or that died of a respiratory illness in the 10 days prior to illness onset?
Yes No Unknown
If YES, was the contact in the U.S.A. or international?
US International Unknown
If International, in which country or countries?
County: _________________ Date(s) of Contact: _______________________________________________________
County: _________________ Date(s) of Contact: _______________________________________________________
In the 10 days prior to illness onset:
Did the case-patient have close contact (within 1 meter (3 feet)) with a person (e.g. caring for, speaking with, or touching) who is a suspected, probable or confirmed novel (including avian and pandemic) human influenza A case within the week prior to illness onset?
YES No Unknown
If YES:
a. Did the patient directly touch or provide physical care for the probable or confirmed case?
YES No Unknown
b. Did the patient speak to or touch or any items belonging to the probable or confirmed case?
YES No Unknown
In the 10 days prior to illness onset:
Did the case-patient visit or stay in the same household with anyone who died during or following the visit?
Yes No Unknown
If this case-patient has a diagnosis of novel influenza A virus infection that has not been laboratory confirmed, is there an epidemiologic link between this patient and a laboratory-confirmed or probable novel influenza A case?
Yes No Unknown
In the 10 days prior to illness onset:
Did the case-patient seek care for an unrelated health condition in a healthcare facility known to be simultaneously caring for other suspected or confirmed human cases of avian or novel influenza?
Yes No Unknown
Exposures-Contact with Poultry and Other Animals
Are any sick or dead animal(s) present in the case-patient’s home, village, neighborhood, or workplace?
Yes No Unknown
If YES, which of following are present? (check all that apply)
Chickens/poultry Wild birds Pigs Other (specify)_______________________
If YES, what is the status of the animals during the two weeks prior to case-patient illness onset?
Well-appearing Diseased Dead (approximate date of death) __________________
If there are sick poultry, are they vaccinated against influenza?
Yes No Unknown
If there are sick pigs, are they vaccinated against influenza?
YES No Unknown
In the 10 days prior to illness onset, did the case-patient have contact with any of the following animals? (check all that apply)
Chickens/poultry Wild birds Pigs Other (specify)_________________________________
If the patient had contact with animals, please answer the following questions, otherwise skip to the Medical History section:
What was the nature of the contact (check all that apply)?
Direct touching (specify animal(s)) ____________
Proximity within 1 meter but not touching (specify animal(s))______________
If the case-patient directly touched the bird(s) or other animal(s), which of the following did the patient do with the animal:
(check all that apply)
Carry/handle Slaughter/butcher Prepare for consumption Other (specify) _________________
If the case-patient directly touched the bird(s) or other animal(s), approximately how many sick or dead birds/animals did the patient touch?
One only 2-5 6-20 21-100 >100
What species of bird(s) or other animal(s) did the case-patient come in contact with? (directly or within 1 meter)
Species #1_________________ Species #2_________________ Species #3_________________
What was the status of the bird(s) or other animal(s) during the two weeks PRIOR to case-patient illness onset?
Well-appearing Diseased Dead (approximate date of death) ____________________________
What is the status of the bird(s) or other animal(s) AFTER the onset of illness in the case-patient?
Well-appearing Diseased Dead (approximate date of death) ____________________________
Where did the contact occur? (check all that apply)
Live animal market Commercial animal farm Backyard animals Inside home
Cockfighting Slaughterhouse Veterinary contact Hunting
Wildlife Other contact___________________________
Are the bird(s) or other animal(s) that the case-patient came in contact with vaccinated with any of following influenza vaccines?
H1 H3 H5 Not vaccinated Unknown vaccination status
Was the contact in the US or international?
US International Unknown
If contact was in the US, in which city and state did it occur?
City: ______________ State: ________________ Date: ______________
City: ______________ State: ________________ Date: ______________
If contact was international, in which country or countries did it occur?
City_______________ Province______________ Country: _________________ Dates: __________________
City_______________ Province______________ Country: _________________ Dates: __________________
Answer the remaining questions in this section in terms of the 10 days prior to the onset of the patient’s illness:
Did the case-patient touch (handle, slaughter, butcher, prepare for consumption) animals (including poultry, wild birds, or swine) or their remains in an area where influenza infection in animals or novel influenza in humans has been suspected or confirmed in the last month?
Yes No Unknown
Was the case-patient exposed to animal (including poultry, wild birds, or swine) remains in an area where influenza infection in animals or novel influenza in humans has been suspected or confirmed in the last month?
Yes No Unknown
Was the case-patient exposed to environments contaminated by to animal feces (including poultry, wild birds, or swine) in an area where influenza infection in animals or novel influenza in humans has been suspected or confirmed in the last month?
Yes No Unknown
Did the case-patient consume raw or undercooked animals (including poultry, wild birds, or swine products) in an area where influenza infections in animals or novel influenza in humans has been suspected or confirmed in the last month?
Yes No Unknown
Did the patient visit an agricultural event, farm, petting zoo or place where pigs live or were exhibited (state or county fair) in the last month?
Yes No Unknown
Did the patient have direct contact with pigs at an agricultural event, farm, petting zoo or place where pigs were exhibited (state or county fair) in the last month?
Yes No Unknown
Did the case-patient handle samples (animal or human) suspected of containing influenza virus in a laboratory or other setting?
Yes No Unknown
Medical History-Vaccination Status
Was the case-patient vaccinated against human influenza in the past year?
Yes No Unknown
If YES, date of vaccination ____/____/____
Type of vaccine: Inactivated Live Attenuated Unknown
Was the case-patient vaccinated against avian influenza A (H5N1)?
Yes No Unknown
If YES, date of vaccination: ____/____/____
Type of vaccine: _________________
Medical History-Past Medical History
Is the case-patient pregnant?
Yes (weeks pregnant)____________ No Unknown
Does the case-patient have any of the following?
a. Asthma yes no unknown
Other chronic lung disease yes no unknown (If YES, specify) _______________________
Chronic heart or circulatory disease yes no unknown (If YES, specify) _______________________
Metabolic disease (including diabetes mellitus) yes no unknown (If YES, specify) _______________________
Kidney disease yes no unknown (If YES, specify) _______________________
Cancer in the last 12 months yes no unknown (If YES, specify) _______________________
Immunosuppressive condition (such as HIV infection, cancer, chronic corticosteroid therapy, diabetes, or organ transplant recipient)
yes no unknown (If YES, specify) _______________________
Other chronic diseases yes no unknown (If YES, specify) _______________________
Is the case-patient on chronic drug therapy?
Yes No Unknown
If yes, complete table below
Drug |
Dose |
Frequency |
Date Initiated |
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mg |
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mg |
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mg |
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mg |
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mg |
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Has the case-patient smoked at least 100 cigarettes in their life? (100 cigarettes = approximately 5 packs) yes no unknown
If YES, does the patient now smoke cigarettes: everyday some days not at all
Medical History-Illness onset and presenting symptoms
Date of illness onset _________________ (DD/MM/YYYY)
Date(s) of outpatient medical presentation(s) (clinic location, name):
Clinic #1 name: __________________ Date(s): _________________ (DD/MM/YYYY) Telephone #: _____________ Fax #: __________________
Address: __________________________________________________________________________
Clinic #2 name: __________________ Date(s): _________________ (DD/MM/YYYY) Telephone #: _____________ Fax #: __________________
Address: __________________________________________________________________________
Date(s) of hospital admission(s):
Hospital #1 Name: _______________________ Telephone#______________________ Fax #: ____________________
Address: __________________________________________________________________________________
Admission date: __________________ (DD/MM/YYYY)
Discharged (specify date) ______________________ Transferred (specify date) ___________
Hospital #2 Name: _______________________ Telephone#______________________ Fax #: ____________________
Address: __________________________________________________________________________________
Admission date: __________________ (DD/MM/YYYY)
Discharged (specify date) ______________________ Transferred (specify date) ___________
Within the last 7 days, has the case-patient experienced any of the following medical conditions:
Coughing YES NO Unknown
Diarrhea YES NO Unknown
Difficulty breathing YES NO Unknown
(or shortness of breath)
Eye infection YES NO Unknown
Fever (_____°) temp if known YES NO Unknown
Feverishness YES NO Unknown
Headache YES NO Unknown
Muscle aches YES NO Unknown
Rash YES NO Unknown
Runny nose YES NO Unknown
Seizures YES NO Unknown
Sore throat YES NO Unknown
Vomiting YES NO Unknown
Other symptom(s) YES NO (specify)________________________
Medical History-Treatment, Clinical Course, and Outcome
Did the case-patient receive antiviral medications?
Yes No Unknown
If yes, complete table below
Drug |
Dose # 1 |
Dose #1 Date Initiated (DD/MM/YYYY) |
Dose #1 Date Discontinued (DD/MM/YYYY) |
Dose #2 |
Dose #2 Date Initiated (DD/MM/YYYY) |
Dose #2 Date Discontinued (DD/MM/YYYY) |
Oseltamivir |
mg |
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mg |
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Zanamivir |
mg |
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mg |
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Rimantadine |
mg |
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mg |
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Amantadine |
mg |
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mg |
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Other ____________ |
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Did the case-patient receive antibacterial medications?
Yes No Unknown
If yes, complete table below
Drug |
Date Initiated |
Date Discontinued |
Dosage (if known) |
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mg |
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mg |
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mg |
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mg |
Did the case-patient receive steroids?
Yes No Unknown
If yes, complete table below
Drug |
Date Initiated |
Date Discontinued |
Dosage (if known) |
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mg |
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mg |
Did the case-patient receive aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs)?
Yes No Unknown
If yes, complete table below
Drug |
Date Initiated |
Date Discontinued |
Dosage (if known) |
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mg |
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mg |
Was the case-patient admitted to an intensive care unit (ICU)?
Yes No Unknown
Did this case-patient receive mechanical ventilation?
Yes No Unknown
Did the case-patient have acute respiratory distress syndrome (ARDS)?
Yes No Unknown
What was the outcome for the case-patient?
Alive Died Unknown
If the patient is ALIVE, what is the current disposition of the case-patient?
Still hospitalized Discharged to home Discharged to nursing care facility (specify name) ___________________
Unknown Other (specify) ___________________
If the patient DIED, please list date of death _______________________(DD/MM/YYYY)
List the ICD-9CM diagnoses at ADMISSION and for each indicate if the diagnosis is a new diagnosis.
1. _ _ _. _ _ New Unknown 4. _ _ _. _ _ New Unknown
2. _ _ _. _ _ New Unknown 5. _ _ _. _ _ New Unknown
3. _ _ _. _ _ New Unknown 6. _ _ _. _ _ New Unknown
List the ICD-10 diagnoses at ADMISSION and for each indicate if the diagnosis is a new diagnosis.
1. _ _ _. _ _ New Unknown 4. _ _ _. _ _ New Unknown
2. _ _ _. _ _ New Unknown 5. _ _ _. _ _ New Unknown
3. _ _ _. _ _ New Unknown 6. _ _ _. _ _ New Unknown
List the ICD-9CM diagnoses at discharge and for each indicate if the diagnosis is a new sequelae of this hospitalization
1. _ _ _. _ _ New Unknown 4. _ _ _. _ _ New Unknown
2. _ _ _. _ _ New Unknown 5. _ _ _. _ _ New Unknown
3. _ _ _. _ _ New Unknown 6. _ _ _. _ _ New Unknown
List the ICD-10 diagnoses at discharge and for each indicate if the diagnosis is a new sequelae of this hospitalization
1. _ _ _. _ _ New Unknown 4. _ _ _. _ _ New Unknown
2. _ _ _. _ _ New Unknown 5. _ _ _. _ _ New Unknown
3. _ _ _. _ _ New Unknown 6. _ _ _. _ _ New Unknown
If ICD-9CM or ICD-10 diagnoses at ADMISSION are not available, write in diagnosis and indicate if the diagnosis is a new diagnosis.
1. _________________________ New Unk 4. _________________________ New Unk
2. _________________________ New Unk 5. _________________________ New Unk
3. _________________________ New Unk 6. _________________________ New Unk
If ICD-9CM or ICD-10 diagnoses at DISCHARGE are not available, write in diagnosis and indicate if the diagnosis is a new sequelae of this hospitalization.
1. _________________________ New Unk 4. _________________________ New Unk
2. _________________________ New Unk 5. _________________________ New Unk
3. _________________________ New Unk 6. _________________________ New Unk
Medical History-Laboratory and Diagnostic Testing
Did the case-patient have a chest x-ray or chest CT scan performed?
Yes No not performed Unknown
If YES, which test was performed? (check all that apply)
Chest CT Chest X-ray
If either test was performed, what was the result?
Normal Abnormal Unknown
If abnormal, was there evidence of pneumonia?
Yes No Unknown
Did the case-patient have a CT scan/MRI of the head or brain?
Yes No not performed Unknown
If YES, were there any acute neurologic abnormalities?
Yes No Unknown
List the following laboratory test results UPON initial admission:
White blood cell (WBC) count __________________ Unknown
Lymphocyte count __________________ Unknown
Neutrophil count __________________ Unknown
Platelet count __________________ Unknown
Did the patient have any of the following laboratory abnormalities at any time during the hospitalization?
Leukopenia (white blood cell count <5,000 leukocytes/mm3)
Yes No Unknown
Lymphopenia (total lymphocytes <800/mm3 or lymphocytes <15% of total WBC)
Yes No Unknown
Thrombocytopenia (total platelets <150,000/mm3)
Yes No Unknow
Were bacterial cultures performed?
Yes No Unknown
If YES, were any positive?
If positive, complete table below
Site (Urine, Blood, CSF, Pleural, Ascitic) |
Date Performed |
Date Positive |
Organism grown |
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Were non-influenza viral tests performed?
Yes No Unknown
If yes, complete table below
Site (Urine, Blood, CSF, Pleural, Ascitic) |
Date Performed |
Result |
Organism |
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Influenza Specific Diagnostic tests:
Test 1
Specimen type:
NP swab NP aspirate Nasal swab Nasal aspirate Sputum
Oropharyngeal swab Endotracheal aspirate Chest tube fluid
Broncheoalveolar lavage specimen (BAL) Serum
Other
Date collected: __/__/__
|
RT-PCR Yes or No |
Direct fluorescent antibody (DFA) |
Viral culture |
Rapid antigen test |
CDC RT-PCR |
Influenza A |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
H1 |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
|
Negative Positive Inconclusive Pending Not tested |
H3 |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
|
Negative Positive Inconclusive Pending Not tested |
H5 |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
|
Negative Positive Inconclusive Pending Not tested |
H7 |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
|
Negative Positive Inconclusive Pending Not tested |
Influenza B |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Test type and result: (check all boxes that apply)
Test Location if not Hospital Laboratory______________________
Test 2
Specimen type:
NP swab NP aspirate Nasal swab Nasal aspirate Sputum
Oropharyngeal swab Endotracheal aspirate Chest tube fluid
Broncheoalveolar lavage specimen (BAL) Serum
Other
Date collected: __/__/__
Test type and result: (check all boxes that apply)
|
RT-PCR Yes or No |
Direct fluorescent antibody (DFA) |
Viral culture |
Rapid antigen test |
CDC RT-PCR |
Influenza A |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
H1 |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
|
Negative Positive Inconclusive Pending Not tested |
H3 |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
|
Negative Positive Inconclusive Pending Not tested |
H5 |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
|
Negative Positive Inconclusive Pending Not tested |
H7 |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
|
Negative Positive Inconclusive Pending Not tested |
Influenza B |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Test Location if not Hospital Laboratory______________________
Test 3
Specimen type:
NP swab NP aspirate Nasal swab Nasal aspirate Sputum
Oropharyngeal swab Endotracheal aspirate Chest tube fluid
Broncheoalveolar lavage specimen (BAL) Serum
Other
Date collected: __/__/__
Test type and result: (check all boxes that apply)
|
RT-PCR Yes or No |
Direct fluorescent antibody (DFA) |
Viral culture |
Rapid antigen test |
CDC RT-PCR |
Influenza A |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
H1 |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
|
Negative Positive Inconclusive Pending Not tested |
H3 |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
|
Negative Positive Inconclusive Pending Not tested |
H5 |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
|
Negative Positive Inconclusive Pending Not tested |
H7 |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
|
Negative Positive Inconclusive Pending Not tested |
Influenza B |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Negative Positive Inconclusive Pending Not tested |
Test Location if not Hospital Laboratory______________________
Specimen Tracking
Indicate when and what type of specimens (including sera) were sent to CDC and CDCID number, if known
__/__/__ Specimen type _________________CDCID#_________________
__/__/__ Specimen type _________________CDCID#_________________
__/__/__ Specimen type _________________CDCID#_________________
| File Type | application/msword |
| File Title | Novel and Pandemic Influenza Case Investigation Form |
| Author | acy9 |
| Last Modified By | Lenee Blanton |
| File Modified | 2010-10-27 |
| File Created | 2009-12-30 |